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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> FMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES TOR LOCAL'AGENCY:USE,ONLY- <br /> YES NO REPORT BEEN FILED 7 YES ❑ NO ;j HEREBY:CEfMFY.THAT.4 HAVE Dis*BUTEDTHI$INFORMATION ACCORDING TgTHE: <br /> DLSTRIBUTK*SHOWN ON THE.INSTHUCTION SHEET ON THE BACK PAGE OF:THIS FORM <br /> REPORT DATE CASE i1 .7 <br /> n <br /> rq DM� <br /> 0d 1 Q <br /> � 7 : N :., ... ...-. .... --:: DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } `-f` ' r� s to7 } ra 3 <br /> 03 <br /> w q PRESENTING ❑ OWNERIOPERA ❑ REGIONAL BOARD COMPANY OR AGENCY NAME ,�/�,r �f <br /> °C LOCAL AGENCY ❑ OTHER �,V <br /> 2 . <br /> a ADDRESS EC, LC/lL `tJ. �4+ri ves �� <br /> 2q, STATE ZIPSTREET cm <br /> w NAME CONTACT PERSON <br /> PHONE� 'tl�, VI Wl+ tfi4 ❑ UNKNOWN YY/�i/ � C�/J'V (J} �J 3) -73—']/1,i-7, <br /> Z <br /> Oa c ADDRESS - <br /> En <br /> LU <br /> oZ 6 0 I sT ' A ro, �'D vb�a2��/'�- GTREEr � <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE. <br /> < ADDRESS <br /> O J y Q <br /> w SIRE C6[lNfY <br /> m <br /> CROS9 ST rL f Ir <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zz Co <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> 4 G . _ <br /> (Sj NAME QUANTITY LOST(GALLONS) <br /> wQ <br /> i G J UNKNOWN <br /> N z L, ! IL�� LF ..D `.' UNKNOWN <br />( i DATE DIVERrzo <br /> I HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LU <br /> i w MI .I 02of 5o1 �Y -7y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN lXI REMOVE CONTENTS JJ�j CLOSE TANK 6 REMOVE Q REPAIR PIPING <br /> Q u O Y � " c <br /> o HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK <br /> CLOSE TANK&FILL IN PLACE [:]CHANGE PROCEDURE <br /> U /� a s <br /> YES C] NO IF YE5.DATE DMi -1 o ✓drI r ❑REPLACE TANK Q OTHER <br /> C3 <br /> iDSOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> 00TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> c a F-1PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zz c ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION. <br /> cr <br /> w LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY - r ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U y ❑ REMEDIATKSN PIAN ❑ CASE CLOSED(CLLANUP COMPLETED OR UNNECESSARY] ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> t ❑ EXCAVATE IL DISPOSE{ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED B10 DEGRADATION(IT) <br /> 4 Z fsU esu ran oFrNar <br /> 00 <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) C] PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> I w< ❑ CONTAINMENT'BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑. VENT SOIL(VS) <br /> 1. ¢ VACUUM EXTRACT(VE) OTHER(OT) <br /> HSC 0(890) <br />